Basic Information
| Provider Information | |||||||||
| NPI: | 1073835328 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SMITH | ||||||||
| FirstName: | WILLIAM | ||||||||
| MiddleName: | EDGAR | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DMD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | SMITH | ||||||||
| OtherFirstName: | BILL | ||||||||
| OtherMiddleName: | E. | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | BLDG 2441 21ST STREET | ||||||||
| Address2: | US ARMY DENTAL ACTIVITY | ||||||||
| City: | FORT CAMPBELL | ||||||||
| State: | KY | ||||||||
| PostalCode: | 42223 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2707988751 | ||||||||
| FaxNumber: | 2709560266 | ||||||||
| Practice Location | |||||||||
| Address1: | BLDG 2441 21ST STREET | ||||||||
| Address2: | US ARMY DENTAL ACTIVITY | ||||||||
| City: | FORT CAMPBELL | ||||||||
| State: | KY | ||||||||
| PostalCode: | 42223 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2707988751 | ||||||||
| FaxNumber: | 2709560266 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/26/2010 | ||||||||
| LastUpdateDate: | 07/14/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 122300000X | DS7100 | TN | Y | Dental Providers | Dentist |
ID Information
| ID | Type | State | Issuer | Description | 58-1943033 | 01 | GA | TAX ID | OTHER |